PA Lookup

If you have questions about prior authorizations, please call:

Member and Recipient Service Line: 1-877-685-2415

Provider Support Service Line: 1-855-250-1539

Filter By:
Clear Filters
12437 Results

Special Services: After Hours

Service Code
99053 (CPT) Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Special service (or miscellaneous office services) CPT codes represent urgent or emergent services that are provided under special circumstances. Special service CPT codes are adjunct services to outpatient evaluation and management services.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

  • a. Documentation in the medical record must substantiate that the service was provided

in accordance with this policy.

  • b. Special services cannot be billed when a scheduled appointment begins during posted

office hours and ends after posted office hours are over.

  • c. One special service is billable per beneficiary per date of service.a. Special services codes are not covered when routine medically necessary

services or health maintenance services are provided to beneficiaries.

Examples of some routine medical services and health maintenance services are:

  • 1. Scheduled appointments for medically necessary non-emergent and

non-urgent medical care.

  • 2. Appointments scheduled outside of posted office hours for the

convenience of the provider.

  • b. Special Services CPT codes are not covered when the service is provided in

a hospital emergency department by physicians assigned to cover the emergency department.

  • c. Special Services CPT codes are not covered when the service is provided in

the inpatient setting

Exclusions

Special services codes are not covered when routine medically necessary services or health maintenance services are provided to beneficiaries. Examples of some routine medical services and health maintenance services are: a. Adult preventive medicine health assessments for Medicaid beneficiaries 21 years of age and older. b. Health Check screenings for Medicaid beneficiaries up to 21 years of age.

  • 1. Dental services shall be provided on a restricted basis in accordance with criteria adopted by the Department to implement this subsection.”

Place of Service

Outpatient, Office

How to Submit

N/A - No authorization is required

Resources

Special Services: After Hours

Service Code
99058 (CPT) Service(s) provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Special service (or miscellaneous office services) CPT codes represent urgent or emergent services that are provided under special circumstances. Special service CPT codes are adjunct services to outpatient evaluation and management services.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

  • a. Documentation in the medical record must substantiate that the service was provided

in accordance with this policy.

  • b. Special services cannot be billed when a scheduled appointment begins during posted

office hours and ends after posted office hours are over.

  • c. One special service is billable per beneficiary per date of service.a. Special services codes are not covered when routine medically necessary

services or health maintenance services are provided to beneficiaries.

Examples of some routine medical services and health maintenance services are:

  • 1. Scheduled appointments for medically necessary non-emergent and

non-urgent medical care.

  • 2. Appointments scheduled outside of posted office hours for the

convenience of the provider.

  • b. Special Services CPT codes are not covered when the service is provided in

a hospital emergency department by physicians assigned to cover the emergency department.

  • c. Special Services CPT codes are not covered when the service is provided in

the inpatient setting

Exclusions

Special services codes are not covered when routine medically necessary services or health maintenance services are provided to beneficiaries. Examples of some routine medical services and health maintenance services are: a. Adult preventive medicine health assessments for Medicaid beneficiaries 21 years of age and older. b. Health Check screenings for Medicaid beneficiaries up to 21 years of age.

  • 1. Dental services shall be provided on a restricted basis in accordance with criteria adopted by the Department to implement this subsection.”

Place of Service

Outpatient, Office

How to Submit

N/A - No authorization is required

Resources

Special Services: After Hours

Service Code
99060 (CPT) Service(s) provided on an emergency basis, out of the office, which disrupts other scheduled office services, in addition to basic service
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Special service (or miscellaneous office services) CPT codes represent urgent or emergent services that are provided under special circumstances. Special service CPT codes are adjunct services to outpatient evaluation and management services.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

  • a. Documentation in the medical record must substantiate that the service was provided

in accordance with this policy.

  • b. Special services cannot be billed when a scheduled appointment begins during posted

office hours and ends after posted office hours are over.

  • c. One special service is billable per beneficiary per date of service.a. Special services codes are not covered when routine medically necessary

services or health maintenance services are provided to beneficiaries.

Examples of some routine medical services and health maintenance services are:

  • 1. Scheduled appointments for medically necessary non-emergent and

non-urgent medical care.

  • 2. Appointments scheduled outside of posted office hours for the

convenience of the provider.

  • b. Special Services CPT codes are not covered when the service is provided in

a hospital emergency department by physicians assigned to cover the emergency department.

  • c. Special Services CPT codes are not covered when the service is provided in

the inpatient setting

Exclusions

Special services codes are not covered when routine medically necessary services or health maintenance services are provided to beneficiaries. Examples of some routine medical services and health maintenance services are: a. Adult preventive medicine health assessments for Medicaid beneficiaries 21 years of age and older. b. Health Check screenings for Medicaid beneficiaries up to 21 years of age.

Dental services shall be provided on a restricted basis in accordance with criteria adopted by the Department to implement this subsection.”

Place of Service

Outpatient, Office

How to Submit

N/A - No authorization is required

Resources

Anesthesia complicated by utilization of total body hypothermia (List separately in addition to code for primary anesthesia procedure)

Service Code
99116 (CPT) Anesthesia complicated by utilization of total body hypothermia (List separately in addition to code for primary anesthesia procedure)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Anesthesia complicated by utilization of controlled hypotension (List separately in addition to code for primary anesthesia procedure)

Service Code
99135 (CPT) Anesthesia complicated by utilization of controlled hypotension (List separately in addition to code for primary anesthesia procedure)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Anesthesia complicated by emergency conditions (specify) (List separately in addition to code for primary anesthesia procedure)

Service Code
99140 (CPT) Anesthesia complicated by emergency conditions (specify) (List separately in addition to code for primary anesthesia procedure)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Moderate (Conscious) Sedation Clinical Coverage Policy No: 1L-2 AKA Procedural Sedation and Analgesia (PSA)

Service Code
99151 (CPT) Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the m
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Moderate (conscious) sedation/Procedural sedation and analgesia (PSA) is the use of medication to depress the level of consciousness in a patient while allowing the patient to continually and independently maintain a patent airway and respond appropriately to verbal commands or gentle stimulation.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

Intraservice time begins with administration of the sedation agent(s), requires continuous face-to-face attendance, and ends when personal contact by the physician or dentist providing the sedation concludes.

Exclusions

Medicaid will not reimburse moderate sedation codes 99155 through 99157 when billed with codes in Appendix G in the nonfacility setting. Codes 99151 through 99157 are not billable with anesthesia codes 00100 through 01999 or pulse oximetry codes 94760 through 94762.

Place of Service

Office, Hospital, Outpatient hospital, Ambulatory surgical center, Nursing facility.

How to Submit

N/A - No authorization is required

Resources

Moderate (Conscious) Sedation Clinical Coverage Policy No: 1L-2 AKA Procedural Sedation and Analgesia (PSA)

Service Code
99152 (CPT) Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the m
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Moderate (conscious) sedation/Procedural sedation and analgesia (PSA) is the use of medication to depress the level of consciousness in a patient while allowing the patient to continually and independently maintain a patent airway and respond appropriately to verbal commands or gentle stimulation.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

Intraservice time begins with administration of the sedation agent(s), requires continuous face-to-face attendance, and ends when personal contact by the physician or dentist providing the sedation concludes.

Exclusions

Medicaid will not reimburse moderate sedation codes 99155 through 99157 when billed with codes in Appendix G in the nonfacility setting. Codes 99151 through 99157 are not billable with anesthesia codes 00100 through 01999 or pulse oximetry codes 94760 through 94762.

Place of Service

Office, Hospital, Outpatient hospital, Ambulatory surgical center, Nursing facility.

How to Submit

N/A - No authorization is required

Resources

Moderate (Conscious) Sedation Clinical Coverage Policy No: 1L-2 AKA Procedural Sedation and Analgesia (PSA)

Service Code
99153 (CPT) Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the m
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Moderate (conscious) sedation/Procedural sedation and analgesia (PSA) is the use of medication to depress the level of consciousness in a patient while allowing the patient to continually and independently maintain a patent airway and respond appropriately to verbal commands or gentle stimulation.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

Intraservice time begins with administration of the sedation agent(s), requires continuous face-to-face attendance, and ends when personal contact by the physician or dentist providing the sedation concludes.

Exclusions

Medicaid will not reimburse moderate sedation codes 99155 through 99157 when billed with codes in Appendix G in the nonfacility setting. Codes 99151 through 99157 are not billable with anesthesia codes 00100 through 01999 or pulse oximetry codes 94760 through 94762.

Place of Service

Office, Hospital, Outpatient hospital, Ambulatory surgical center, Nursing facility.

How to Submit

N/A - No authorization is required

Resources

Moderate (Conscious) Sedation Clinical Coverage Policy No: 1L-2 AKA Procedural Sedation and Analgesia (PSA)

Service Code
99155 (CPT) Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 min
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Moderate (conscious) sedation/Procedural sedation and analgesia (PSA) is the use of medication to depress the level of consciousness in a patient while allowing the patient to continually and independently maintain a patent airway and respond appropriately to verbal commands or gentle stimulation.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

Intraservice time begins with administration of the sedation agent(s), requires continuous face-to-face attendance, and ends when personal contact by the physician or dentist providing the sedation concludes.

Exclusions

Medicaid will not reimburse moderate sedation codes 99155 through 99157 when billed with codes in Appendix G in the nonfacility setting. Codes 99151 through 99157 are not billable with anesthesia codes 00100 through 01999 or pulse oximetry codes 94760 through 94762.

Place of Service

Office, Hospital, Outpatient hospital, Ambulatory surgical center, Nursing facility.

How to Submit

N/A - No authorization is required

Resources

Moderate (Conscious) Sedation Clinical Coverage Policy No: 1L-2 AKA Procedural Sedation and Analgesia (PSA)

Service Code
99156 (CPT) Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 min
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Moderate (conscious) sedation/Procedural sedation and analgesia (PSA) is the use of medication to depress the level of consciousness in a patient while allowing the patient to continually and independently maintain a patent airway and respond appropriately to verbal commands or gentle stimulation.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

Intraservice time begins with administration of the sedation agent(s), requires continuous face-to-face attendance, and ends when personal contact by the physician or dentist providing the sedation concludes.

Exclusions

Medicaid will not reimburse moderate sedation codes 99155 through 99157 when billed with codes in Appendix G in the nonfacility setting. Codes 99151 through 99157 are not billable with anesthesia codes 00100 through 01999 or pulse oximetry codes 94760 through 94762.

Place of Service

Office, Hospital, Outpatient hospital, Ambulatory surgical center, Nursing facility.

How to Submit

N/A - No authorization is required

Resources

Moderate (Conscious) Sedation Clinical Coverage Policy No: 1L-2 AKA Procedural Sedation and Analgesia (PSA)

Service Code
99157 (CPT) Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 min
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Moderate (conscious) sedation/Procedural sedation and analgesia (PSA) is the use of medication to depress the level of consciousness in a patient while allowing the patient to continually and independently maintain a patent airway and respond appropriately to verbal commands or gentle stimulation.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

Intraservice time begins with administration of the sedation agent(s), requires continuous face-to-face attendance, and ends when personal contact by the physician or dentist providing the sedation concludes.

Exclusions

Medicaid will not reimburse moderate sedation codes 99155 through 99157 when billed with codes in Appendix G in the nonfacility setting. Codes 99151 through 99157 are not billable with anesthesia codes 00100 through 01999 or pulse oximetry codes 94760 through 94762.

Place of Service

Office, Hospital, Outpatient hospital, Ambulatory surgical center, Nursing facility.

How to Submit

N/A - No authorization is required

Resources

Screening test of visual acuity, quantitative, bilateral

Service Code
99173 (CPT) Screening test of visual acuity, quantitative, bilateral
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Unit Value

1 unit = 1 event

How to Submit

Please submit your request to Trillium Health Resources

Hyperbaric Oxygenation Therapy

Service Code
99183 (CPT) Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Hyperbaric oxygen (HBO) therapy consists of the exposure of the entire body to 100% oxygen at pressures greater than one atmosphere absolute (ATA) in accordance with accepted clinical protocols for duration and pressure in a mono- or multi-place pressurized chamber.

Authorization Guidelines

Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.

Limits

Initial prior approval covers 30 days; treatment beyond 30 calendar days requires a second prior approval request.

The entire body must be pressurized, and 100% oxygen must be inhaled via the chamber environment, hood tent, face mask, endotracheal tube, or tracheostomy tube.

Limited to two sessions per date of service.

Exclusions

Hyperbaric Oxygenation Therapy is not covered for acute cerebral edema; acute or chronic cerebral vascular insufficiency; acute thermal and chemical pulmonary damage including smoke inhalation with pulmonary insufficiency; aerobic septicemia; anaerobic septicemia and infection other than clostridial; arthritic diseases; cardiogenic shock; chronic peripheral vascular insufficiency except as specifically allowed per the CCP; congenital conditions such as cerebral palsy, autism, and mental retardation; cutaneous, decubitus, and stasis ulcers; exceptional blood loss anemia; hepatic necrosis; multiple sclerosis; myocardial infarction; nonvascular causes of chronic brain syndrome including Pick's disease, Alzheimer's disease, and Korsakoff's disease; organ storage; organ transplantation; pulmonary emphysema; senility; sickle cell crisis; thermal skin burns; systemic aerobic infection; tetanus; and traumatic brain injury. Topical application of oxygen does not meet the definition of HBO therapy and is not covered. HBO therapy is also not covered as a replacement for other standard successful therapeutic measures. The use of hyperbaric oxygen for any type of cutaneous ulcer other than Meleney ulcers is not covered. The policy also states that treatment of multiple sclerosis and brain injury, including autism, cerebral palsy, and stroke, is not approved due to lack of evidence-based medicine.

Place of Service

Inpatient, Outpatient.

Additional Service Specifics

Prior approval is given for an initial period of 30 days. Treatment beyond 30 calendar days requires a second prior approval request.

How to Submit

Please submit your request to Trillium Health Resources

Resources

Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude

Service Code
99184 (CPT) Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

99195 THERAPEUTIC PHLEBOTOMY

Service Code
99195 (CPT) 99195 THERAPEUTIC PHLEBOTOMY
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Unlisted special service, procedure or report

Service Code
99199 (CPT) Unlisted special service, procedure or report
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

Evaluation & Management

Service Code
99202 (CPT) Evaluation & Management
Prior Authorization Required
No
Telephonic Billable
No
Telehealth Billable
Yes
Benefit Plan
State-funded
Age Group
All
Diagnosis Group
Mental Health

Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Unit Value

One CPT code = 1 unit of service.

Limits

  • 1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
  • 2. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
  • 3. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
  • 4. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
  • 5. The provider will communicate and coordinate care with other professionals providing care to the recipient.
  • 6. Telehealth, Virtual Communication, and Hybrid Telehealth services must follow the guidelines and requirements detailed in the State-Funded Telehealth and Virtual Services service definition.

Other Information

Modifier(s):

GT: Telehealth

How to Submit

N/A - No authorization is required

Resources

Evaluation & Management

Service Code
99202 (CPT) Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total
Prior Authorization Required
No
Telehealth Billable
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Intellectual/ Developmental Disability, Mental Health, Substance Use

Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Unit Value

One service code = 1 unit of service

Limits

  • 1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
  • 2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD. MCD is the payor of last resort.
  • 3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
  • 4. The provider will communicate and coordinate care with other professionals providing care to the member.

How to Submit

N/A - No authorization is required

Resources

1E-7 Family Planning Services

Service Code
99202 (CPT) Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Family Planning Medicaid services are provided to an eligible Medicaid beneficiary of childbearing age to temporarily or permanently prevent or delay pregnancy. Medicaid Family Planning is designed to reduce unintended pregnancies and improve the well-being of children and families in North Carolina.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

Limited to one annual assessment evaluation or one comprehensive preventive medicine evaluation per 365 calendar days for FP Medicaid beneficiaries.

An annual office visit assessment is required before any other family planning or family planning-related services are rendered, unless the beneficiary has had an annual assessment, a comprehensive preventive medicine evaluation, or a postpartum exam within the previous 365 days.

Only one annual focused assessment may be billed in a 365-day rolling calendar period.

Annual focused assessments are billed using office or other outpatient evaluation and management visit definitions for new or established patients.

If performed in lieu of a comprehensive preventive medicine evaluation, the annual assessment visit must be billed with the SC modifier.

The Annual Assessment Date is required to be documented on claims for the annual assessment.

Exclusions

FP Medicaid does not cover treatment for acute or chronic conditions discovered during screening. FP Medicaid also does not cover medical conditions unrelated to family planning or family planning-related services; beneficiaries needing non-family planning services must be referred to primary care or a safety net provider. General policy exclusions also apply when the service duplicates another provider's service or is experimental, investigational, or part of a clinical trial. A separate inter-periodic office visit cannot be billed with CPT procedure codes 58300, 58301, 57170, 11981, 11982, or 11983 because the office visit component is already included in reimbursement for those procedures. No claim is filed if, before any service is rendered, the beneficiary confirms they have been sterilized, are post-menopausal, or are otherwise incapable of conceiving or fathering a child; the provider must stop the visit, inform the beneficiary they are not eligible for Family Planning Medicaid services, and refer them to local safety net programs. FP Medicaid does not cover services for beneficiaries who have been sterilized or no longer have a need for family planning services. Hospital emergency room or emergency department services are not covered for FP Medicaid, and after-office-hours codes are not allowed when the service is provided in a hospital emergency room or emergency department.

Place of Service

Non-Telehealth Claims: a. Inpatient hospitals (not applicable for a FP Medicaid beneficiary) b. Outpatient hospital: For a FP Medicaid beneficiary, the only surgical procedure or service allowed requiring outpatient beneficiary registration is sterilization, IUD removal or ultrasound for IUD related complications including missing strings. c. Office: utilizing offices within places of service 11 (Office), 19 (Off Campus Outpatient) or 22 (On Campus Outpatient) d. Ambulatory Surgical Centers (applicable for a FP Medicaid beneficiary for a sterilization. Numeric POS code(s): 02-Telehealth Provided Other than in Patient's Home.

Additional Service Specifics

FP. GT applies only when the service is telehealth billable and delivered by interactive audio-video.

How to Submit

N/A - No authorization is required

Resources